Enhancing Value-Based Care With a Walk-in Clinic: A Primary Care Provider Intervention to Decrease Low Acuity Emergency Department Overutilization.

Background Emergency department overutilization is a known contributor to the high per-capita healthcare cost in the United States. There is a knowledge gap regarding the substitution effect of walk-in clinic availability in primary care provider (PCP) offices and emergency department utilization (EDU). This study evaluates associations between PCP availability and EDU and analyzes the potential cost savings for health systems. Methods A retrospective cohort analysis compared low acuity EDU rates in established patients at a family medicine residency's PCP office before and after walk-in clinic implementation. The practice had 12 providers, 12 residents, and a patient panel of approximately 7,000-8,000. Inclusion criteria were met if patients were: (1) established with the PCP office, (2) had a low acuity emergency department (ED) visit (emergency index score level 4 or 5) OR had a walk-in clinic visit at the family practice. ED visits were tracked from January 2018 to January 2020 and encounters were compared numbers to pre and post-implementation of a walk-in clinic. Cost savings for comparable management was estimated with average price differences for low acuity encounters in the ED versus clinic. Results Over the two-year timeframe, there were 10,962 total visits to the ED by family practice patients, 4,250 of these visits were low acuity. Despite gross monthly increases of EDU from 2018-2020, after implementation of a walk-in clinic in 2019, rates of total EDU decreased by 1.5% and low acuity utilization rates also decreased. The average annual patient census nearly doubled from 5,763 to 8,042. T-tests confirmed statistical significance with p-values <0.05. Average low acuity ED visits ($437) cost 4.9 times more than comparable PCP office visits ($91). Managing 2,387 patients in the walk-in clinic resulted in an estimated annual cost savings of $825,902. Conclusion Extended walk-in availability in primary care offices provides non-ED capacity for low acuity management and might mitigate low acuity ED utilization while providing more cost-effective care. This study supports similarly described pre-hospital diversions in reducing ED over-utilization by increasing access to care. Higher levels of evidence are needed to establish causality.

The association between the regular use of early-term labor induction and improved birth outcomes: new evidence from an Italian hospital.

BACKGROUND: Associations have been recently reported between the frequent use of early-term preventive labor induction and improvements in multiple parameters of birth health. We sought to replicate these findings in an Italian hospital. METHODS: The outcomes of 120 consecutively delivered women who were exposed to the alternative method of care were compared to the outcomes of 159 women who received standard management. The primary and secondary outcomes were group cesarean delivery rate and group adverse outcome index score. RESULTS: Exposed women had a higher induction rate, a lower cesarean delivery rate (1.7% vs. 43.4%), and a lower group AOI Score (0.2 vs.5.8). CONCLUSIONS: Exposure to high levels of early term preventive labor induction was associated with a lower group cesarean delivery rate and improvement in several other major birth outcomes. An adequately powered randomized controlled trial is needed to further explore this alternative method of care.

US term stillbirth rates and the 39-week rule: a cause for concern?

BACKGROUND: More than a decade ago an obstetric directive called "the 39-week rule" sought to limit "elective" delivery, via labor induction or cesarean delivery, before 39 weeks 0 days of gestation. In 2010 the 39-week rule became a formal quality measure in the United States. The progressive adherence to the 39-week rule throughout the United States has caused a well-documented, progressive reduction in the proportion of term deliveries occurring during the early-term period. Because of the known association between increasing gestational age during the term period and increasing cumulative risk of stillbirth, however, there have been published concerns that the 39-week rule-by increasing the gestational age of delivery for a substantial number of pregnancies-might increase the rate of term stillbirth within the United States. Although adherence to the 39-week rule is assumed to be beneficial, its actual impact on the US rate of term stillbirth in the years since 2010 is unknown. OBJECTIVE: To determine whether the adoption of the 39-week rule was associated with an increased rate of term stillbirth in the United States. STUDY DESIGN: Sequential ecological study, based on state data, of US term deliveries that occurred during a 7-year period bounded by 2007 and 2013. The patterns of the timing of both term childbirth and term stillbirth were determined for each state and for the United States as a whole. RESULTS: A total of 46 usable datasets were obtained (45 states and the District of Columbia). During the 7-year period, there was a continuous reduction in all geographic entities in the proportion of term deliveries that occurred before 39 weeks of gestation. The overall rate of term stillbirth, when we compared 2007-2009 with 2011-2013, increased significantly (1.103/1000 vs 1.177/1000, RR 1.067, 95% confidence interval 1.038-1.096). Furthermore, during the 7-year period, the increase in the rate of US term stillbirth appeared to be continuous (estimated slope: 0.0186/1000/year, 95% confidence interval 0.002-0.035). Assuming 3.5 million term US births per year, and given 6 yearly "intervals" with this rate increase, it is possible that more than 335 additional term stillbirths occurred in the United States in 2013 as compared with 2007. In addition, during the 7-year period, there was a progressive shift in the timing of delivery from the 40th week to the 39th week. Absent this confounding factor, the magnitude of association between the adoption of the 39-week rule and the increase in rate of term stillbirth might have been greater. CONCLUSIONS: Between 2007 and 2013 in the United States, the adoption of the 39-week rule caused a progressive reduction in the proportion of term births occurring before the 39th week of gestation. During the same interval the United States experienced a significant increase in its rate of term stillbirth. This study raises the possibility that the 39-week rule may be causing unintended harm. Additional studies of the actual impact of the adoption of the 39-week rule on major childbirth outcomes are urgently needed. Pressures to enforce the 39-week rule should be reconsidered pending the findings of such studies.

What is the optimal gestational age for women with gestational diabetes type A1 to deliver?

OBJECTIVE: Type A1 gestational diabetes mellitus (A1GDM), also known as diet-controlled gestational diabetes, is associated with an increase in adverse perinatal outcomes such as macrosomia and Erb palsy. However, it remains unclear when to deliver these women because optimal timing of delivery requires balancing neonatal morbidities from early term delivery against the risk of intrauterine fetal demise (IUFD). We sought to determine the optimal gestational age (GA) for women with A1GDM to deliver. STUDY DESIGN: A decision-analytic model was built to compare the outcomes of delivery at 37-41 weeks in a theoretical cohort of 100,000 women with A1GDM. Strategies involving expectant management until a later GA accounted for probabilities of spontaneous delivery, indicated delivery, and IUFD during each week. GA-associated risks of neonatal complications included cerebral palsy, infant death, and Erb palsy. Probabilities were derived from the literature, and total quality-adjusted life years were calculated. Sensitivity analyses were used to investigate the robustness of the baseline assumptions. RESULTS: Our model showed that induction at 38 weeks maximized quality-adjusted life years. Within our cohort, delivery at 38 weeks would prevent 48 stillbirths but lead to 12 more infant deaths compared to 39 weeks. Sensitivity analysis revealed that 38 weeks remains the optimal timing of delivery until IUFD rates fall <0.3-fold of our baseline assumption, at which point expectant management until 39 weeks is optimal. CONCLUSION: By weighing the risks of IUFD against infant deaths and neonatal morbidities from early term delivery, we determined that the ideal GA for women with A1GDM to deliver is 38 weeks.

Second stage of labor and epidural use: a larger effect than previously suggested.

OBJECTIVE: To examine the length of second stage of labor with and without an epidural during labor. METHODS: This was a retrospective cohort study of 42,268 women who delivered vaginally with normal neonatal outcomes. Median lengths and 95th percentiles of second stage of labor were compared by epidural use with stratification by parity. Statistical comparisons were performed using the Kruskal-Wallis test and Kaplan-Meier survival analysis. RESULTS: Compared with women without epidural use, the 95th percentile length of second stage for nulliparous women was 197 minutes without epidural and 336 minutes with epidural (P<.001), a difference of 2 hours and 19 minutes. For multiparous women, the 95th percentile length of second stage was 81 minutes without epidural and 255 minutes with epidural (P<.001), a difference of 2 hours and 54 minutes. CONCLUSION: Although recommendations for intervention during the second stage of labor have been made based on a 1-hour difference in the setting of epidural use, it appears that the 95th percentile duration is actually more than 2 hours longer with epidural during labor for both nulliparous and multiparous women.

Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes.

OBJECTIVE: To test the association of elective induction of labor at term compared with expectant management and maternal and neonatal outcomes. METHODS: This was a retrospective cohort study of all deliveries without prior cesarean delivery in California in 2006 using linked hospital discharge and vital statistics data. We compared elective induction at each term gestational age (37-40 weeks) as defined by The Joint Commission with expectant management in vertex, nonanomalous, singleton deliveries. We used multivariable logistic regression to test the association of elective induction and cesarean delivery, operative vaginal delivery, maternal third- or fourth-degree lacerations, perinatal death, neonatal intensive care unit admission, respiratory distress, shoulder dystocia, hyperbilirubinemia, and macrosomia (birth weight greater than 4,000 g) at each gestational week, stratified by parity. RESULTS: The cesarean delivery rate was 16%, perinatal mortality was 0.2%, and neonatal intensive care unit admission was 6.2% (N=362,154). The odds of cesarean delivery were lower among women with elective induction compared with expectant management across all gestational ages and parity (37 weeks [odds ratio (OR) 0.44, 95% confidence interval (CI) 0.34-0.57], 38 weeks [OR 0.43, 95% CI 0.38-0.50], 39 weeks [OR 0.46, 95% CI 0.41-0.52], 40 weeks [OR 0.57, CI 0.50-0.65]). Elective induction was not associated with increased odds of severe lacerations, operative vaginal delivery, perinatal death, neonatal intensive care unit admission, respiratory distress, shoulder dystocia, or macrosomia at any term gestational age. Elective induction was associated with increased odds of hyperbilirubinemia at 37 and 38 weeks of gestation and shoulder dystocia at 39 weeks of gestation. CONCLUSION: Elective induction of labor is associated with decreased odds of cesarean delivery when compared with expectant management. LEVEL OF EVIDENCE: : II.

Induction of labor compared to expectant management in low-risk women and associated perinatal outcomes.

OBJECTIVE: We sought to examine the association of labor induction and perinatal outcomes. STUDY DESIGN: This was a retrospective cohort study of low-risk nulliparous women with term, live births. Women who had induction at a given gestational age (eg, 39 weeks) were compared to delivery at a later gestation (eg, 40, 41, or 42 weeks). RESULTS: Compared to delivery at a later gestational age, those induced at 39 weeks had a lower risk of cesarean (adjusted odds ratio [aOR], 0.90; 95% confidence interval [CI], 0.88-0.91) and labor dystocia (aOR, 0.88; 95% CI, 0.84-0.94). Their neonates had lowered risk of having 5-minute Apgar <7 (aOR, 0.81; 95% CI, 0.72-0.92), meconium aspiration syndrome (aOR, 0.30; 95% CI, 0.19-0.48), and admission to neonatal intensive care unit (aOR, 0.87; 95% CI, 0.78-0.97). Similar findings were seen for women who were induced at 40 weeks compared to delivery later. CONCLUSION: Induction of labor in low-risk women at term is not associated with increased risk of cesarean delivery compared to delivery later.

Risk of stillbirth and infant death stratified by gestational age.

OBJECTIVE: To estimate the multiple dimensions of risk faced by pregnant women and their health care providers when comparing the risks of stillbirth at term with the risk of infant death after birth. METHODS: This is a retrospective cohort study that included all nonanomalous, term deliveries in the state of California from 1997 to 2006 (N=3,820,826). The study compared infant mortality rates after delivery at each week of term pregnancy with the rates of a composite fetal-infant mortality that would occur after expectant management for 1 additional week. RESULTS: The risk of stillbirth at term increases with gestational age from 2.1 per 10,000 ongoing pregnancies at 37 weeks of gestation up to 10.8 per 10,000 ongoing pregnancies at 42 weeks of gestation. At 38 weeks of gestation, the risk of expectant management carries a similar risk of death as delivery, but at each later gestational age, the mortality risk of expectant management is higher than the risk of delivery (39 weeks of gestation: 12.9 compared with 8.8 per 10,000; 40 weeks of gestation: 14.9 compared with 9.5 per 10,000; 41 weeks of gestation: 17.6 compared with 10.8 per 10,000). CONCLUSION: Infant mortality rates at 39, 40, and 41 weeks of gestation are lower than the overall mortality risk of expectant management for 1 week.

The risk of stillbirth and infant death stratified by gestational age in women with gestational diabetes.

OBJECTIVE: We sought to compare the different mortality risks between delivery and expectant management in women with gestational diabetes mellitus (GDM). STUDY DESIGN: This is a retrospective cohort study that included singleton pregnancies of women diagnosed with GDM delivering at 36-42 weeks' gestational age in California from 1997 through 2006. A composite mortality rate was developed to estimate the risk of expectant management at each gestational age incorporating the stillbirth risk during the week of continuing pregnancy plus the infant mortality risk at the gestational age 1 week hence. RESULTS: In women with GDM, the risk of expectant management is lower than the risk of delivery at 36 weeks (17.4 vs 19.3/10,000), but at 39 weeks, the risk of expectant management exceeds that of delivery (relative risk, 1.8; 95% confidence interval, 1.2-2.6). CONCLUSION: In women with GDM, infant mortality rates at 39 weeks are lower than the overall mortality risk of expectant management for 1 week; absolute risks of stillbirth and infant death are low.

Risk adjustment in maternity care: the use of indirect standardization.

PURPOSE: Annual US national rates of family physicians providing maternity care are decreasing and rates of cesarean delivery are increasing. Family physicians tend to have lower cesarean delivery rates than obstetrician specialists, but this association is usually explained by an assumed lower pre-delivery risk for cesarean delivery. This study was developed to compare the estimated risk of cesarean delivery in patients of the two specialties. METHODS: A retrospective cohort study within an urban teaching hospital compared 100 family- physician treated subjects to 300 subjects treated by obstetrician-specialists. Risk factors for cesarean delivery were identified, and an indirect standardization procedure was used to compare the pre-38 week of gestation risk of cesarean delivery in the two groups. RESULTS: The patients treated by family physicians had a projected pre-38 week of gestation risk of cesarean delivery (17.4%) that was similar to the actual rate of cesarean delivery in the obstetrician-specialist group (16.7%). The Standardized Cesarean Delivery Ratio was 1.04. CONCLUSION: Lower cesarean delivery rates provided by family physicians may not be simply due to case-mix issues. Additional studies comparing the pre-delivery estimation of cesarean delivery risk would be helpful in measuring the relative levels of obstetric risk of patients treated by different maternity-care provider types.

The active management of impending cephalopelvic disproportion in nulliparous women at term: a case series.

BACKGROUND: The Active Management of Risk in Pregnancy at Term (AMOR-IPAT) protocol has been associated in several studies with significant reductions of group cesarean delivery rate. Present within each of these studies were nulliparous women with risk factors for cephalopelvic disproportion. Risk factors for cephalopelvic disproportion in nulliparous women are especially important because they represent the precursors for the most common indication for primary cesarean delivery. CASES: Three examples of exposure of urban nulliparous women to the AMOR-IPAT protocol are presented. Each woman's risk factor profile for Cephalopelvic Disproportion (CPD) was used to estimate her Upper Limit of Optimal Time of Vaginal Delivery for CPD (UL-OTDcpd). Labor management and clinical outcomes for each case are presented. A simple table summarizing induction rates and birth outcome rates of exposed versus nonexposed nulliparous women is also presented. CONCLUSION: Because the mode of delivery of the first birth substantially impacts birth options in later pregnancies, the impact of AMOR-IPAT on nulliparous patients is particularly important. Determining the UL-OTDcpd in nulliparous patients, and carefully inducing each patient who has not entered labor by her UL-OTDcpd, may be an effective way of lowering rates of cesarean delivery in nulliparous women.

The association between increased use of labor induction and reduced rate of cesarean delivery.

AIM: An association was recently reported between a low cesarean section delivery rate and a method of obstetrical care that involved the frequent use of risk-guided prostaglandin-assisted preventive labor induction. We sought to confirm this finding in a subsequent group of pregnant women. METHODS: A retrospective cohort study design was used to compare the outcomes of 100 consecutively delivered women, who were exposed to the alternative method of care, with the outcomes of 300 randomly chosen women who received standard management. The primary outcome was group cesarean delivery rate. Secondary outcomes were rates of neonatal intensive care unit admission, low 1-minute Apgar score, low 5-minute Apgar score, and major perineal trauma. RESULTS: Women exposed to the alternative method of obstetrical care had a higher induction rate (59% vs. 16.3%, p < 0.001), a more frequent use of prostaglandins for cervical ripening (32% vs. 13%, p < 0.001), and a lower cesarean delivery rate (7% vs. 20.3%, p = 0.002). Exposed women did not experience higher rates of other adverse birth outcomes. CONCLUSIONS: Exposure to an alternative method of obstetrical care that used high levels of risk-driven prostaglandin-assisted labor was again associated with two findings: a lower group cesarean delivery rate and no increases in levels of other adverse birth outcomes. An adequately powered randomized controlled trial is needed to further explore this alternative method of care.

"One end has nothing to do with the other:" patient attitudes regarding help seeking intention for depression in gynecologic and obstetric settings.

Many women rely on their obstetrician/gynecologist (OB/GYN) as their primary contact with the health care delivery system. There have been few studies exploring patient views on getting help for depression from these providers. The purpose of this study is to assess help seeking intention for depression and identify beliefs which moderate this intention. Telephone interviews of women following a routine gynecologic visit or in the immediate postpartum period (regarding prenatal care) were used to assess intention to seek help from their providers in a case of depression. For women who lacked this intention, related beliefs were elicited with the open ended question "why not?" Among the 225 women in the study more than half receiving gynecologic care (59%) and nearly a third of women who received prenatal care (29%; p < 0.001) stated they would not seek help from their OB/GYN for depression. Report that a prenatal provider had mentioned depression was associated with help seeking intention for depression but was not independent of confounding variables. Beliefs among women who lacked help seeking intention clustered into two attitude themes: 1) an OB/GYN is the wrong doctor for depression care and 2) OB/GYN is not a good setting for depression care. Many women have attitudes which reduce their intention to seek help for depression from their OB/GYN. Interventions aiming to increase delivery of depression care in these settings should consider these beliefs in their design.

Tracking the cell hierarchy in the human intestine using biochemical signatures derived by mid-infrared microspectroscopy.

Markers of gastrointestinal (GI) stem cells remain elusive. We employed synchrotron Fourier-transform infrared (FTIR) microspectroscopy to derive mid-infrared (IR) spectra along the length of human GI crypts. Tissue sections (10-µm thick) were floated onto BaF2 windows and image maps were acquired of small intestine and large bowel crypts in transmission mode with an aperture of ≤10 µm×10 µm. Counting upwards in a step-size (≤10 µm) fashion from the crypt base, IR spectra were extracted from the image maps and each spectrum corresponding to a particular location was identified. Spectra were analyzed using principal component analysis plus linear discriminant analysis. Compared to putative crypt base columnar/Paneth cells, those assigned as label-retaining cells were chemically more similar to putative large bowel stem cells and, the small intestine transit-amplifying cells were closest to large bowel transit-amplifying cells; interestingly, the base of small intestine crypts was the most chemically-distinct. This study suggests that in the complex cell lineage of human GI crypts, chemical similarities as revealed by FTIR microspectroscopy between regions putatively assigned as stem cell, transit-amplifying and terminally-differentiated facilitates identification of cell function.